Healthcare Provider Details

I. General information

NPI: 1568119352
Provider Name (Legal Business Name): FISSEHA GEBREGZIABHER GEBREMEDHIN DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5335 W SUBLETT RD
ARLINGTON TX
76017-1184
US

IV. Provider business mailing address

10110 WALNUT ST APT 109
DALLAS TX
75243-5156
US

V. Phone/Fax

Practice location:
  • Phone: 817-890-9009
  • Fax:
Mailing address:
  • Phone: 214-780-9777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number14490
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: